Am Fam Physician. 2004;70(7):1219-1220
A 60-year-old, small-framed woman with good general health but a strong family history of osteoporosis presents for her well-woman examination. Because she meets screening criteria for osteoporosis,1 her family physician orders a bone density test. Her T-scores are −2.8 at the lumbar spine and −1.5 at the femoral neck. Osteoporosis is diagnosed, and the patient begins treatment with a bisphosphonate and calcium/vitamin D supplements. Two years later, the patient’s lumbar-spine bone density is stable, but her femoral-neck T-score has declined by 1.5 percent. She has not had a fracture. The patient asks if the change in her femoral-neck T-score represents a treatment failure and whether this finding warrants referral to a subspecialist.
We can ask the same question about this patient that we ask about any patient with chronic disease: Who should take responsibility for her care? A recent editorial in the Archives of Internal Medicine2 promotes shared responsibility by primary care physicians and subspecialists for osteoporosis management. A strategy in which primary care physicians take the lead in managing this common disorder is optimal because we are the only ones who can implement preventive measures on a population level. Osteoporosis screening and routine management does not require subspecialist input. For example, in the case of the patient described above, the T-score decrease was relatively small. The density at the femoral neck was still within the osteopenia range, and the lumbar spine bone density was stable. She had not incurred a fracture while taking a bisphosphonate. Her score change did not represent a treatment failure, and she did not require referral to a specialty clinic.
In 2002, nearly 22 million women in the United States had osteopenia (bone mineral density below normal but above the level for a diagnosis of osteoporosis). More than 8 million U.S. women 50 years and older currently have osteoporosis, and the number of affected women is expected to exceed 14 million by the year 2020.3 Women with osteoporosis are at increased risk for death or disability from fractures of the hip, spine, or wrist. Osteoporotic fractures could cost as much as $20 billion per year in the United States, with hip fractures accounting for over one third of total expenditures.4 Only primary care physicians can reach patients early enough to screen for and treat osteoporosis before fracture is imminent.
As summarized by Zizic in this issue of American Family Physician,5 well-designed randomized controlled trials have demonstrated the efficacy of risedronate (Actonel) and alendronate (Fosamax) in decreasing vertebral and nonvertebral (including hip) fractures in women with osteoporosis and a history of fracture at baseline. Alendronate also has been shown to decrease fracture incidence in women with osteoporosis but no previous fracture.6
Despite the availability of evidence-based screening guidelines and effective treatment agents,1 implementation of preventive and therapeutic measures is disturbingly low, even in patients who already have incurred fractures.7,8 Whose fault is the poor implementation? A recent survey9 found that more than 80 percent of family physicians wanted to be better informed about bone density testing and osteoporosis treatment. However, many of these physicians felt that available guidelines were out of date or otherwise not useful. A recent review indicated lack of guideline uniformity, low screening rates, and low intervention rates.10
Most osteoporosis research and guideline development still are conducted by subspecialists who are unfamiliar with the unique practice demands and needs of family physicians. It is clear that family physicians need to be involved in all phases of the process—from research to guideline formation and implementation—to ensure the construction and implementation of clinical aids that are tailored to our specialty and practice environments. Tools for screening, diagnosing, treating, and monitoring patients are available. We no longer can wait for someone else to take charge.